Thank you for visiting our office. We want your visit to be pleasant and comfortable. Please help us by completing this form.
All of this information is completely confidential.
Responsible Party Information
Dental Insurance Information
INSURANCE AUTHORIZATION & FINANCIAL RESPONSIBILITY AGREEMENT
Dental History (New Patients Only)
I have reviewed the information on this form and it is accurate to the best of my knowledge. I authorize and give consent for the dentist and/or team of this office to perform dental services as agreed between doctor and patient and/or guardian, including the use of local anesthetic and other medication as indicated.
- NOTICE OF PRIVACY PRACTICES -
This notice describes how health information about you may be used and disclosed,and how you can get access to this information.Please review this notice carefully. Your privacy is important to us.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your protected health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 3/8/2010 andwill remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain;including health information we created or received prior tothe changes. Before we make a significant change in our privacy practices, we will change this Notice and provide the new Notice at our practice location.We will also distribute it upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices or additional copies of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you without authorization for the following purposes:
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us. If you feelthat:
You may file a complaintusing the contact information listed at the end of this Notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaintwith the U.S. Department of Health and Human Services upon request.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Dr. Damon B. Thompson
250 South Main Street, Suite 212
Blacksburg, Virginia 24060